CMO ANNUAL REPORT 2004
killed in Nottingham in very similar circumstances to earlier deaths. Progress in addressing this problem was reviewed in my 2002 Annual Report and drew attention to the production of national guidance on the safe administration of intrathecal chemotherapy, which was issued to the NHS in November 2001, based on the recommendations of the Toft report into the death of Wayne Jowett. This guidance was much stricter than anything previously published – for example, establishing and maintaining a register of named personnel who are certified as trained and competent to carry out intrathecal chemotherapy tasks. Progress has also been made with manufacturers to design and test connectors that will help prevent the wrong drug being injected and, should this prove possible, it will act as an additional safeguard. According to the guidance issued in November 2001, NHS Trusts were required to complete a checklist, confirming compliance, by the end of December 2001. By March 2002, 32 (21%) NHS Trusts remained non-compliant and it was Summer 2003 before full compliance was achieved. Compliance was achieved only by: • discussions between the hospitals
concerned and the Department of Health’s then performance management arm (the directorates of health and social care) • interventions by the nine Regional Directors of Public Health • direct intervention by myself as Chief Medical Officer • a warning by a health minister that chairs of non-compliant NHS Trust Boards would be personally held to account. Following feedback from peer review visits, revised guidance was issued in October 2003 for implementation by 30 November 2003. However, by the following summer (June 2004), 30 (21%) NHS Trusts were still considering or assessing it and, by the following autumn (November 2003), 17 (12%) NHS Trusts were still not able to report compliance. It took warning letters and telephone calls to chief executives of those NHS Trusts to achieve full reported compliance across the NHS by January 2005. A national cancer peer review programme started in November 2004 to assess, among other things, compliance with 50 intrathecal chemotherapy measures based on the revised guidance. Of the 19 NHS Trusts providing intrathecal chemotherapy services that had been reviewed by April 2005, nine
5 Compliance with patient safety alerts in the NHS
TIMELINE
COMPLIANCE WITH INTRATHECAL CHEMOTHERAPY GUIDANCE NOVEMBER 2001 – NEW GUIDANCE ISSUED CONTAINING RIGOROUS REQUIREMENTS FOR PATIENT SAFETY WITH COMPLIANCE SET FOR END DECEMBER 2001 MARCH 2002 – REVIEW OF SELF-ASSESSMENT RETURNS SHOWS 32 (21%) NHS TRUSTS NOT FULLY COMPLIANT JANUARY 2003 – REVIEW OF FURTHER SELFASSESSMENT RETURNS SHOWS 44 (34%) NHS TRUSTS NOT FULLY COMPLIANT MAY 2003 – EXTERNAL PEER REVIEW SHOWS 26 (18%) NHS TRUSTS NON-COMPLIANT JUNE 2003 – ALL NHS TRUSTS CONFIRM COMPLIANCE OCTOBER 2003 – REVISED GUIDANCE ISSUED JUNE 2004 – 30 (21%) NHS TRUSTS STILL ASSESSING THE NEW GUIDANCE OR HAVE NOT COMPLETED IMPLEMENTATION NOVEMBER 2004 – 17 (12%) NHS TRUSTS STILL NOT REPORTING COMPLIANCE NOVEMBER 2004 – GUIDANCE CONVERTED INTO 50 MEASURES AGAINST WHICH TRUSTS COULD BE PEER REVIEWED DECEMBER 2004 – 3 (2%) NHS TRUSTS NOT YET COMPLIANT JANUARY 2005 – ALL NHS TRUSTS REPORTING COMPLIANCE MAY 2005 – FURTHER EXTERNAL PEER REVIEW VISITS SHOW 9 OUT OF 19 NHS TRUSTS VISITED ARE NOT SATISFACTORILY COMPLIANT REMAINDER OF NHS TRUSTS PROVIDING INTRATHECAL CHEMOTHERAPY TO BE VISITED OVER THE NEXT 18 MONTHS
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